| NPI | 1508376658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1550) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA185251) |
| Enumeration Date | 2017-10-03 |
| Last Update Date | 2025-12-05 |